Is medicine for the suits or the white coats?

This refrain has become commonplace among physicians, who worry that patient care, the essence of medicine, is increasingly taking a backseat to bureaucratic demands on safety metrics and electronics health records as well as corporate measures of efficiency. Without physicians, after all, there is no health care system for administrators to administrate, they say. Not only do top-down regulations make patient care more cumbersome, they significantly distract from the joy and meaning that so many seek when they choose a career in medicine.

As a medical student, I have heard these words all too often from many types of physicians, ranging from primary care providers to anesthesiologists. Research, moreover, seems to back this up. A 2013 study from Johns Hopkins showed that interns spend 40% of their time in front of a computer screen compared to just 12% with patients. A 2010 meta-analysis on the distribution of physicians’ time in the hospital setting showed that, across 13 different studies, physicians consistently spent significantly more time on activities related to indirect patient care compared to direct patient care. And a 2006 study showed that the same reality to be true for emergency physicians.

Even more worrisome is that these day-to-day frustrations seem to be changing physician behavior on a larger scale. According to a 2013 report, Jackson Healthcare, a major physician staffing company, anticipates an increasing void in the healthcare field because “physicians are preparing to leave medicine early either through retirement or a change in their career field” due to “feeling disconnected from their patients because of increasing regulatory and reimbursement restraints.” Anecdotally, my conversations with fellow medical students and physicians echo this report as more and more are choosing to forego patient care for consulting, industry, entrepreneurship, and other “alternative careers in medicine,” as they’re often called.

The problem with the perspective of “leave us alone,” however, is that physicians, like many groups, have been notoriously ineffective at self-policing. The good old days yielded unsustainable growth of health care costs to 18% of GDP as well as the now infamous report from the Institute of Medicine, “To Err is Human,” which shed light on preventable medical errors that led to between 44,000 to 98,000 deaths in hospital per year. Meanwhile, the growth of insurance, technology, and larger health care systems in the second half of the 20th century only made the problems more complicated.

The “suits,” in a way, were a response to the increasing complexity, cost, and questionable quality of care. In the 10 years following the IOM report, we appeared to be making some, albeit slow, progress on patient safety according to a 2009 paper in Health Affairs due to increasing pressures, standards, and requirements on hospitals and providers. More recently, the quality initiatives in the ACA seem to have led to decreased hospital readmission rates and incidents of patient harm (though some argue these trends preceded the law).

Moreover, the increased focus on cost in the ACA has led to a slowing of U.S. health care expenditures to record lows over the last three years, a trend that has persisted even after the economy started to recover from the recession. Although there is some evidence that this slower growth of national health care expenditures really began a decade ago due to a decline in real income and shift of patients from private to public insurance, the provisions for new insurance structures, payment policies, and models of care delivery and payment in the ACA will be crucial towards sustaining this trend, which would allow us to spend more of our country’s resources on education, infrastructure, defense, and anything-not-health care.

Doctors, as the ones who actually deliver the basic unit of health care, must be involved in the development and implementation of these administrative and national policies. Unlike other stakeholders in this complex system, physicians are in the unique position of understanding the “reality on the ground,” of what it means to actually deliver patient care in different settings. Provider input, for example, is critical in determining which quality metrics are useful vs. simply easy to measure or what kind of electronic health record is beneficial vs. merely burdensome.

At a time when physicians are increasingly feeling slighted and retreating from the spotlight, wishing administration would just let them be, disengaging from public policy (AMA membership is at an all-time low and continues to decrease), and hoping “Obamacare” would simply disappear, we need their insight more than ever. Hospital systems, insurance companies, and certainly the U.S. health care system are incredibly complex entities, whose effective and cost-sensitive management requires a variety of disparate skills and training that only different professionals, whether physicians, policymakers, or administrators, can provide. The question should not be who is in charge but how can we work together.

So is medicine for the suits or the white coats? For the system to work at its best, it has to be for both.

Is medicine for the suits or the white coats? 25 comments

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Peter Elias

“So is medicine for the suits or the white coats? For the system to work at its best, it has to be for both.”

Wrong answer, because the question is wrong.

Medicine is for the patients. Full. Stop.

“At a time when physicians are increasingly feeling slighted and retreating from the spotlight, wishing administration would just let them be, disengaging from public policy (AMA membership is at an all-time low and continues to decrease), and hoping “Obamacare” would simply disappear, we need their insight more than ever. Hospital systems, insurance companies, and certainly the U.S. health care system are incredibly complex entities, whose effective and cost-sensitive management requires a variety of disparate skills and training that only different professionals, whether physicians, policymakers, or administrators, can provide. The question should not be who is in charge but how can we work together.”

No mention of patients having even input, let alone a controlling voice. I find this very disheartening.

rbthe4th2

Amen!

The fact remains that more inclusion of patients and getting rid of more suits would be helpful. We’re the ones who are taking the risk. We are the ones being asked to go round and round to doctors until we get an answer, on our own dime. Since we’re the ones paying the cost, the system is for us, we should be included. I’m not referring to people who can’t make a sound evidence based decision like Ms. Jenny vaccines cause autism either.

Patient Kit

I agree. Asking whether medicine is FOR doctors or FOR suits, with no mention at all of it being FOR patients is truly a disheartening and disturbing question. The optimist in me hopes that the OP, a med student, didn’t mention patients only because he assumed that was understood and didn’t need to be said. But it does need to be said.

http://ekive.blogspot.com ekivemark

Without patients neither have a job.

The patient should be at the center and the suits and white coats work together to deliver the most effective care.

Mike Henderson

I agree with the concept of your statements.

I am assuming you are a patient, but you do not see what goes on behind the scenes – the financial whips and carrots in the system are at odds with putting patients first. Physicians do not have the leverage to work with the suits to put patients first and make medicine as enjoyable to practice as it should be. The suits have the money and power and won’t be letting go of the reins any time soon. What should happen and what will happen are two different things.

However, nothing stays the same. When times are difficult, you either basically choose to do something or do nothing. Most choose nothing. But not all.

I feel for the people you’ll treat when you start your practice, since you obviously will view them as objects, or at best meat puppets, not actual human participants in the care process.

Medicine must be, first and foremost, for people. The people it treats, the people who form the community that medicine hopes to keep from needing its direct services (public health), the people who look for up to date information on how they can live their lives to the fullest.

Please pull your head out of [pick your metaphor] and recognize that without people-commonly-called-patients, you’d be in law school. Or worse.

JR

While I agree that doctors are at the front lines and need to be more involved… I’m glad I’m not alone in feeling this missed a big gaping hole: Where is the patient input?

Steven Reznick

It should be all about the patient. There relationship with their doctor should be determining the direction of care. The suits as hospital administrators,medical equipment and device executives and lobbyists, pharmaceutical execs and their lobbyists coupled with an aging population with chronic illnesses is the reason health care takes up so much of the GNP.

SteveCaley

With all respect, Simon, one of your paragraphs glares out as rubbish.

“The problem with the perspective of “leave us alone,” however, is that physicians, like many groups, have been notoriously ineffective at self-policing. The good old days yielded unsustainable growth of health care costs to 18% of GDP as well as the now infamous report from the Institute of Medicine, “To Err is Human,” which shed light on preventable medical errors that led to between 44,000 to 98,000 deaths in hospital per year. Meanwhile, the growth of insurance, technology, and larger health care systems in the second half of the 20th century only made the problems more complicated.
I suspect you are innocently repeating sheer propaganda.
To Err Is Human was an IOM study in 1999 which I fear nobody but me has read – I mean, actually read and not cited third-hand. It pointed out the recent and accelerating tendency of obliterating traditional redundancy in medicine for the purpose of “cost-savings” had come to dominate American medicine in the 1990’s, and was harming patients. That topic refers to the “preventable deaths” of which you speak. The suits were putting kerosene on the wildfire then; we switched to gasoline. I ask that you refrain from quoting the buzz-phrases from the press until you read the document. It, more than anything else, castigated the move to corporate medicine. The toxic effects are now dumped on the physicians as “ineffective in self-policing.”
Healthcare moves around way too much money to be left alone. If you read the press releases, Poland was unable to effectively self-police its people’s terroristic activity against the German state; therefore, the German state exercised reasonable and moderate self-defense on September 1, 1939. Even dictators need press releases to gobble things up.

pmanner

Steve, this is a very good point. My condolences on reading To Err is Human.
A further point: TEIH was based on two, count ‘em, two retrospective chart reviews. One looked at hospital discharges in New York in 1984, the other looked at hospital discharges in Colorado and Utah in 1991. Basically, a nurse looked through a stack of charts, and then a physician looked at the stuff she picked out.
In both studies, adverse events occurred in about 3% of discharges, and the researchers decided whether these reflected negligence. About 25-30% did in their view.
So we have created an entire industry, and justified an enormous and probably futile exercise in fingerpointing, because of two subjective chart review papers. From 30 years ago. Still do things the way you did in 1984? Didn’t think so.

Simon, here’s a tip: NEVER believe the authorities. Read the data yourself!

SteveCaley

Unlike the small minority of us who are trained to doubt statistics, the general public assumes that anything that is said in an Authoritative And Reliable manner is true.

SteveCaley

Like in the old USSR, no tattered and disproven proposition ever elicited sufficient ridicule to drive it into extinction. The clumsy and irritating proposition that “doctors just aren’t businessmen” has been around for at least thirty years – and has failed, and failed, and failed again. Let’s make it completely fail.
It is too late to rescue – American medicine will fail, like the Warsaw Pact failed. Their citizens bolted, walked off the job. Pretty soon, the American patients will, too.

Andy

‘The “suits,” in a way, were a response to the increasing complexity, cost, and questionable quality of care.’

You are dangerously mistaken. The suits are about increasing profits and making money. They couldn’t care less about quality. In fact, they can’t even recognize it – they equate quality and revenue.

Papa Omega

Wow, I cant believe there are so many negative people trying to pick apart little sentences and not getting the whole idea of the article. This person should be commanded on his efforts to better the system. If he does not mention the word “patient” in his question it does not mean that the patient’s well being is not a priority of this post, neither does it give you a right to start judging his character or his intentions. I am sure as a medical student he understands that medicine is “ALL ABOUT THE PATIENT” however what he is talking about is the conflict between the physician and the administration where doctors are tasked with helping the patient (i.e. ALL ABOUT THE PATIENT) and administration is interested in making huge profits.
I’m sure some would love to have free healthcare and have doctors work for free because making money as a doctor is “absurd” but if you have an MD or DO next to your name you should not simply pick apart every word of the article and look at the entire picture and encourage the writer to continue talking about his ideas, raise awareness and get involved in health policy.

Mike Henderson

Thanks for sparing me the pain of reading the report. But perhaps I should anyways as it seems to have exerted significant influence of the perception of physicians.

Mike Henderson

FIrst, I did read the article with the assumption the author understood the healthcare system is about the patient. After reading the comments, it still seems apparent that assumption is correct.

Second, I would rephrase some statements. For example “Is medicine for the suits or whitecoats?” My question is, can the whitecoats rectify the perverse relationship with the suits to return the practice of medicine to putting patients first? My imagination goes blank when trying to imagine how that would happen on a level playing field, with cooperation from the suits.

Third, the statement “Doctors, as the ones who actually deliver the basic unit of health care, must be involved in the development and implementation of these administrative and national policies. Unlike other stakeholders in this complex system, physicians are in the unique position of understanding the “reality on the ground,” of what it means to actually deliver patient care in different settings,” seems to best sum up the point of the article. I absolutely agree – physicians absolutely must be a part of the design of the health care system. It is too complicated for the suits to do by themselves, and if we allow them, it is to the peril of the patient and physician. So, how physicians can be a part of the policy making process in the system as the system is currently run is hard to imagine, but we must find a way.

It isn’t that medicine is for the suits or the white coats. It has always been about the patients. However to succeed we need to embrace the science of business and the science of medicine. We need to collaborate together.

Agreed…the white coats need to become the suits to save the basic principles of medicine

Mike Henderson

To play the devil’s advocate and take some points from the article, did physicians give the suits ammunition and opportunity to create the problem?

Arby

Which is kind of odd considering they will be patients if not now, then someday.

Simon Basseyn

Author’s response:

In response to the questions and comments about the role of patients and patient input, I certainly agree that the patient’s stake is paramount. After all, as one commenter phrased it, without patients there is no medicine or healthcare. Moreover, the role of “patient” is transient and each one of us will be inevitably be a patient at some point – even doctors and administrators as well as the majority of society that does not fall in one of the above two buckets.

However, without the people who take care of patients and those who maintain the complex system that continues to be the largest portion of our economy, there is also no healthcare system. The purpose of my article was certainly not to discount the role of patients but to present the need for individuals with a variety of skills – clinical medicine, research, management, operations, strategy, and so on – to work together on the side of medicine that functions to take care of patients.

The lack of discussion of patients was, therefore, not meant to minimize the importance of their role but to reflect my limited focus of discussing the portion of medicine that is charged with their care. I hope this serves as a useful clarification, and one that I should have made clear at the outset.

-Simon Basseyn

Some dude

The answer is the White Coats need to become the suits. Of course an MBA has no idea how to manage a busy ED, OR, or ICU when stuff hits the fan. We also need to work together to better guide government mandates, on both state and national levels.
The government (sometimes) means well, but its policies are often misguided. For instance, you state “quality initiatives have lowered readmissions”, but the truth is that physicians are just reclassifying “inpatient admission” as “observation.” Anyone who tells you otherwise doesn’t work in the ER or as a Hospitalist. These costs are directly transfered to the patient, many of whom are Medicare recipients on limited incomes. Yes we all need more “skin” in the game, but passing the buck to pensioners seems cruel and petty to people who have bought in to the medicare system for years.
Meanwhile, big hospitals are being gobbled up by bigger hospitals, many of whom are either for profit (answering to shareholders), or “non-profit” (who essentialy function as private corporations redistributing profits to administrators and building unecessary buildings that contribute nothing to patient care but increase market share in insured patients who enjoy things like hard-wood floors, espresso machines, and koi gardens in the atrium.)
Funny how doctors are being villified, but no one is asking why a $500 office procedure costs $3000 in a Surgical suite (granted, usually owned by doctors) and $6000 in a hospital outpatient suite (owned by the Hospital groups).